Community Impact Statement Survey

A Community Impact Statement gauges the potential impact of the grant or removal of certain types of NSW Liquor Licences on the local community or broader community. A CIS is also required to be undertaken for licence related authorisations, such as extended trading hours or primary service authorisations.

Name/Corporate Name: *
Contact Person:
Telephone Number: *
Facsimile Number:
E-Mail: *
Survey relates to premises at:

What is your preferred method for us to contact you?

How far away is the Proposed Premises from where you reside or work?  Please distinguish whether the distance is to your place of work or place of residence.

Do you believe the Proposed Premises could adversely affect you, and if so, please specify in what way? 

If you believe the Proposed Premises could adversely affect you, can you suggest any changes to the proposal that could lessen your concerns?
For example, you might be aware of operational policies or procedures at a similar venue, which have been successfully implemented at those premises and which, if adopted by this proposal, would satisfy your concerns.

If on the other hand you believe the Proposed Premises could benefit you in some way please indicate in what way. For example, there may be increased employment opportunities for the community or improved shopping convenience and choice for you.

Do you have any other comments to make regarding the proposal?

Should you have any concerns with the proposal can we contact you to discuss those concerns further? If so, we will contact you by your preferred method indicated above. If you ticked by phone, please indicate when would be a convenient time for us to call you, such as at a particular time of the day or day of the week.
NoYes, during the following times:

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